12.MMSOP 05 –Administration of Medicines
Medication Administration Principles in Domiciliary Care
• Service users will be fully involved in decisions regarding their individual medication and its purpose and staff will have shared with them, in a method which promotes their understanding, the medication Patient Information Leaflet (PIL) provided by the dispensing Pharmacist.
• Before any support with medication is provided, an assessment will be undertaken to establish the service user's capacity to self-manage their medication or the level of medication support required.
• Before medication is administered to any service user, formal consent must be obtained.
• Where a service user is unable to give valid consent due to mental incapacity, best interest meetings will take place and, where it is agreed that it is in the best interest of the service user, including their medical interests, that medication is administered, then formal authorisation for medication administration will be obtained and evidenced in the service user’s Care Plan and medication records
• Medication administration must promote service user independence, choice, privacy, and dignity.
• Medication administration must take account of the service users' cultural and religious values and beliefs.
• Medication must not be used as a form of restraint to sedate service users for the convenience of the staff. This is abuse and a breach of Human Rights
• Medication must only be administered to the service user who has been prescribed that medication
• All Care staff, including those who are not directly concerned with the administration of medicines, will be trained in the understanding of medications, the main types of medication in use, their administrative procedures, and how to look for and report possible adverse reactions, including changes which may require review of the Service User’s medication prescription
• Only staff who have undertaken the medication training, and who have been assessed as competent, will be involved in the administration of the medication
• Records of care staff who are trained and assessed as competent to administer medicines will be held the registered manager
• Covert medication must not be given to a service user who has the capacity to give their consent or refuse medical treatment.
• Care staff must not administer medication from family filled dosette boxes in line with best practice guidance
Types of Medication Support
The care/assessor/registered manager or senior staff are responsible for assessing and agreeing on the type of medication support required and ensuring that the appropriate record keeping and training needs are met. The Service User’s Care Plan will require review as needs change. Involvement with the wider multi-disciplinary team may be required to ensure that the Service User's independence, needs and expectations are met.
In addition to self-management, there are three types of support that might be required with medication administration.
• Level1: Prompting or mechanically assisting with medication administration to support self-management (this is always done under the direction of the service user).
• Level 2: Administering medication
• Level 3: Administering medication using specialised techniques after receiving further training
Procedure
• Care staff will only provide support with medication administration if it is agreed in the Care Plan.
• Wash and thoroughly dry hands and assemble any equipment that may be required, e.g., medicine spoons, tablet cutter. Any liquid medication must be measured into a clearly graduated and marked medication pot or by using an appropriately sized oral syringe which clearly identifies individual millilitre markings.
• Always use disposable powder free gloves when administering medicines
• Check the service user's identity and allergy status - 6 Rights of Medication Administration.
• Check that the service user consents to have their medication. Where a Service User lacks capacity, check that the best interest decision is in place.
• Check the physical state of the medication, including the expiry date and labelling and check that it has been suitably stored. If the medication label and MAR do not appear to match, then advice must be sought from the Registered Manager before administration.
• Check the required dose and any special instructions on the dispensing label (e.g., not to be given with milk or antacids or to be taken with food, etc.) and take appropriate action.
• Contact the registered manager or senior care staff if there are concerns that the dose has already been given by another care staff. Do not give the dose until it is confirmed that it is safe to do so.
• Ensure that the service user is either in a standing position or sitting upright. Staff must not attempt to assist withmedication for service users who are in a prone position. Medicines must be swallowed with plenty of water, e.g., 100-150ml of water or at least half a glass.
• Check that the medication has been taken.
• Record on the appropriate option on the visit task/ MARs or care record that the medicine has been given or that it has been offered and declined. If the service user declines to take a medicine, the care staff must consider waiting a short while before offering it again. Care staff will ask about other factors that may cause a service user to decline their medicine, such as being or not being in pain or discomfort.
• If the service user still declines, the care staff will complete the MARs/ task/care record with the correct code as well as the daily record log. The care staff will report this to the manager immediately The Manager will need to seek clinical advice from the GP or Pharmacist if the Service user declines their medication. Out of hours advice may be sought from 111.
• Return the medicines to the safe storage place as identified on the risk assessment.
• Ensure that the MARs/care records are stored securely and appropriately. Remove gloves and aprons and wash hands.
Administration Do's and Don'ts
• Do only administer medication if you have been trained and assessed as competent to do so
• Do make sure that medication is given at the time agreed on the Care Plan and MAR. The timing of medication administration can be crucial and adherence to medication prescription instructions must be followed. This must be clearly indicated in the medication Care Plan and in the Medication Administration Record
• Do make sure that medicines are given only to the service user for whom they are prescribed, following the prescription instructions
• Do give medicines from the container in which they are supplied. Medication doses will not be put out in advance (potted up) as this can lead to errors and accidents
• Do check where the service user's medication is stored before starting medication administration. It may be in the refrigerator or separate jars or tubs
• Do always check the medication and MAR, do not rely on memory
• Do always ask the service user if they want to take their medication before removing it from the pack. If they decline to take the medication try again a little later. The refusal must be documented, and the GP or Pharmacist telephoned for advice
• If the tablets or capsules are in a pharmacy-filled monitored dosage system (MDS) do open the appropriate section and empty the tablets/capsules into a medicine pot and hand it directly to the Service User
• Do transfer the medication from the bottle or pack into a medication pot and give this directly to the service user
• Do make sure that any variable dose or PRN medication is given as indicated in the Care Plan and what was given is documented.
• Do seek advice if a service user cannot swallow their medication. Advice must be obtained from a health care professional and alternative liquid medication may be able to be prescribed. Medication will not be crushed or split without prior approval from the prescriber as this may affect the way medicines work and can be potentially harmful to the service user.
• Do report any concerns and log any incidents, errors or omissions as soon as you become aware.
• Do mark any medication that has a short shelf life after opening with the date after which it will not be used on the container.
• Do hand over all information regarding changes to medications administration to relevant staff and ensure that they have received and understand the message.
• Do not take medication from its original container and give it to another member of staff to give to the service user, as the person checking the right dose for the right person must also witness the person taking the medication and must be sure that the medication has been taken properly by the service user.
• Do not handle medication but transfer to the medication pot in a non-handling, clean method
• Do not use part-used medication that has been dispensed to one service user, and is no longer required, for any other service user
Splitting Medication
• When it is necessary to split a tablet to provide the required prescribed dose, the supplying pharmacy will be asked to supply the medication as split tablets in an appropriate container
• Where the Pharmacist refuses to supply split medication, a tablet cutter will be used as per the service user's risk assessment.
• Where the tablet is provided in a manufacturer's blister pack, after splitting, the remaining tablet must be disposed of because it cannot be stored correctly until the next required dose
• Disposal will be in line with the medication policy MMPOL36
• Staff will be aware that splitting medication is a last resort as splitting can result in differences in medication fragments altering the therapeutic dose
Crushing Medication
• Crushing medication may alter the way in which a medicine is absorbed and its effect on the body.
• Crushing medication invalidates a product license so crushing medication must always be authorised by the prescriber
• Where it has been agreed with the prescriber that crushing medication is in the service User's best interest, advice from a pharmacist may be sought if required. The prescriber can give authority to crush mediation.
• Other alternatives such as the availability of liquids or other forms of medicines will be discussed
• Written authorisation from the prescriber for each medicine that needs to be crushed, and the period the authorisation applies, must be recorded and retained with the service user's medication records
• Where staff are required to give crushed medication via specialised technique, such as via a PEG Tube, they will only administer when trained and assessed as competent to do so
Time Sensitive Medication
• The times of administering medication are essential and there are often set times for some medication.
• It is important to know if the medication is required to be taken a specified number of hours apart, as taking some medications too closely together can result in toxicity.
• It is important to document clearly that medications have been given on the MAR.
• No double doses must ever be given, e.g., if a service user declines one dose do not give two doses the next time around. This will be recorded on the MAR using the correct reason code.
• Managers will ensure that care staff are able to prioritise their visits for service users who need support with time-sensitive medicines.
• Staff responsible for administration of medication will be made aware of any timesensitive medication
• The Registered Manager will ensure that prescribers, supplying pharmacists and dispensing doctors provide clear written directions on the prescription and dispensing label on how each prescribed medicine will be taken or given, including for time-sensitive medicines. Information must include:
• What the medicine is for
• What dose must be taken?
• What time the dose must be taken, as agreed with the service user
13 MMSOP 06 – Other Routes of Medicines Administration
• Care staff will only provide support with medication administration if it is agreed in the Care Plan.
• Wash and thoroughly dry hands and assemble any equipment that may be required,
• Always use disposable powder free gloves when administering medicines
• Check the service user's identity and allergy status - 6 Rights of Medication Administration.
• Check that the service user consents to have their medication. Where a service user lacks capacity, check that the best interest decision is in place.
• Check the physical state of the medication, including the expiry date and labelling and check that it has been suitably stored. If the medication label and MAR do not appear to match, then advice must be sought from the Registered Manager before administration.
• Check the required dose and any special instructions on the dispensing label.
• Care staff will ensure that the Infection Control Policy and Procedure is followed.
• All staff will ensure that the dignity and privacy of a service user is maintained when administering medication, including via routes other than oral. Irrespective of whether
a service user has the capacity to give informed consent, the service user must be informed of what actions are taking place and they must be treated with compassion at all times.
• Care Plans will detail how the medication is to be administered, including sites for topical application, injections or transdermal patches.
• Where it applies, individual service user risk assessments will be completed for any risks associated with routes of administration.
• Body maps will be used for each topical medication required. Body maps will also be used for detailing transdermal patch sites.
• If a Service User requires non-insulin diabetic injections, the injection sites must be rotated, and a body map and record made in the Service User's notes.
• Where transdermal patches are required, the patches must be disposed of as per the Patient Information Leaflet. Patches that contain a controlled drug will be disposed of as per the medication policy MMPOL36
14.MMSOP 07 Disposal of medicines
Medicines belong to the service user for whom they were prescribed and cannot be removed without their permission. Service users are responsible for disposing of their own medicines safely unless specified in the care plan/medication risk assessment. Care staff may only undertake this task if the patient is unable and there are no relatives or other informal carers to do so. In such circumstances the medicines must be taken directly to the pharmacy or dispensary.
General Disposal
Procedures
Medicines no longer required by the Service User will be disposed of by returning to the dispensing pharmacy.
• At no time may one Service User's prescribed medication be used for any other person.
• No medicines will be thrown in the bin or down a sink or toilet. Any sharp objects (e.g., needles) or other clinical waste will be disposed of into designated bags/containers.
• No out-of-date medicines or discontinued medicines are to be kept. Out-of-date medicines for disposal must be kept separate from medicines in use.
Care staff will only return medicines for disposal to the dispensing pharmacy if:
• The administration of medication is required as part of the Care Plan.
• There are no family, friends or neighbors who can return the medicines.
• They have the consent of the service user.
• They have completed Medication returned to Pharmacy Form (Appendix 4) as a record of disposal.
Disposal applies to:
• Medication that has been discontinued.
• Medication remaining due to a service user's treatment having been changed or discontinued.
• Dispensed doses that have been refused.
• Medication that is past the expiry date.
• Medication remaining after a Service User has died.
Disposal
of Medication from a Monitored Dosage System (MDS) or Packaging Strip
• It will be noted that unused medicines dispensed in a monitored dosage system must be discarded no later than eight weeks after the dispensing date.
• Any unused tablets/capsules removed from an MDS or packaging strip by a Care staff will ideally be placed in a sealed envelope or something similar with the following information added:
• Service User’s name
• Date.
• Time.
• Reason (e.g., refused, dropped on the floor).
• Care Practitioner's name and signature
The care staff must contact the registered manager or senior care in charge and obtain consent from them and from the Service User to take the medication to a pharmacy for disposal. A Medication Return to Pharmacy Form must be completed and an entry made in the Care staff Communication and Visit Log of actions taken. The Medication Return Form must be sent to the registered manager’s office to place it in the Service User's file.
PRN Medication
When required, “PRN” medications in bottles or packs will be checked for expiry dates and sent back to the Pharmacist or dispensing doctor when out of date. Any out-of-date items will be re-ordered from the individual Service User's GP if still required.
Controlled Drugs (CDs)
CDs will be returned to the Pharmacist or dispensing Doctor at the earliest opportunity for safe disposal. When CDs are returned for disposal, a record of the return will be made using a Medication Returned to Pharmacy Form and the Pharmacist or dispensing Doctor MUST provide a signature to note their return.
Disposal of Patches
Used patches will be disposed of by folding back and sticking the adhesive sides together and then disposing of them safely as directed in the Patient Information Leaflet.
Sharps Disposal
Where a Service User’s medication support generates ‘sharps’ (needles, syringes, lancets for finger pricking for testing blood) then these must be disposed of in a designated ‘sharps bin’ supplied through the GP or Community Nursing Team. Care staff will only be providing support with this if it has been agreed as part of the Care Plan, a risk assessment is in place and specific additional training has been undertaken.
Disposal of Liquid Medication
In the event of a Care staff measuring a dose of oral liquid medication and the Service User then refusing to take it, the following actions will be taken:
• Do not return the dose to the medicine bottle.
• Place it in a suitable container, if available.
• Mark it as waste and name the medicine.
• If it will not be going to the pharmacy immediately, ensure that it is stored securely and removed as soon as possible.
The Care staff must make an entry in the Communication and the Visit Log indicating that the dose has been disposed of. The Care staff must also inform the Registered Manager.
Deceased Service Users
Medication belonging to recently deceased service must be kept until any relevant investigations are completed if applicable. Police or courts require them as evidence as part of any investigation into the death of the Service User.
Dropped and single dose disposal
• Dropped tablets can be avoided with good administration technique e.g. preparing doses over a work surface. In the event that a tablet is dropped, the care staff should assess the situation and ask if they want a new dose prepared.
• If medicines are disposed of a note should be made in the daily record of what medicines have been returned to the pharmacy.
• Care staff should not dispose of any medication in household waste or by flushing down the toilet. A small container may be used to return single doses to the pharmacy or dispensing surgery.
• If doses of medication are disposed of, a new prescription may be needed to replace these doses, which the care worker should arrange via their manager.
If care staff remove medicines for disposal, the names and quantities should be recorded, and a copy retained with the care record (see Appendix 4 for returning medication to pharmacy form)
15.MMSOP 08 Record of Medicines Administration
Medication and Care Plan Information
A Service User's Care Plan will include:
• The support needed including details of specific requirements.
• Up-to-date Medication Administration Record(s) detailing current medication where support with administration is required. A list of ‘current medication at date’ must be stored in the Service User's record.
• Contact details of the Prescriber, Community Pharmacist and other appropriate healthcare professionals
• Details of the location where medication is stored in the service user's home and where the service user’s Care Plan is to be stored. In cases where the Service User is at risk of harm and they have been identified as being at risk by the Commissioner or the GP if the medication location is highlighted, the Risk Assessment must clearly indicate that registered manager will inform the Care staff of the location of the medication and the reasons for this process being undertaken.
Medication Assessments
• A full medication assessment must be completed for each Service User. This must include both prescribed medication and any over the counter (OTC) medication
• For service users who need no medication support, the Care Plan Consent Form must indicate that they are self-managed, and any risks associated with this must be identified and recorded
• The medication assessment must indicate the agreed support that the Care staff will deliver
• Care staff must check the Care Plan on each visit and record medication administered, they must also document where a patient has been prompted or assisted on relevant care record
• The medication assessment must be reviewed annually, after an accident, incident or near miss, or if there are any changes to a Service User’s circumstances (including changes to medication), care or health needs
Medication Administration Record (MAR) Information
The Medication Administration Record (MAR) for an individual Service User will include:
• Their name
• Their address
• Their date of birth.
• Any other available person-specific identifiers such as the NHS number.
• Any known drug allergies (if none, then this fact must also be recorded).
• The name, formulation and strength of the medicine
• How the medicine is taken or used (route of administration)
• The dose, time to be taken or used, and any special instructions, e.g., with or after food.
• Any stop date for a medicine
• Reference to any separate specialised administration MAR if one is in use, e.g., warfarin, when required medication
MAR Recording Procedure
Record what you do when you do it. As medicines are administered, if verbal reminders or physical assistance is provided it must be recorded immediately and logged by the person providing the medication support.
• Record any medications not taken, providing a reason.
• Medication with variable doses must be clearly recorded on the MARS with the actual dose given.
• Where there are any changes to the care agreed in the Care Plan, the care staff must report to the Registered Manager. This includes if a Service User refuses medication.
MAR Times
• Where specific times are not detailed on the pre-printed MAR but printed as 'morning', 'lunch, 'tea-time', 'bedtime' (or suitable abbreviations), the manager will check with each individual service user what this means and obtain guidance from the GP if required.
• For example:
• Morning means 8:30 to 10:00
• Lunch means 12:30 to 14:00
• Teatime means 18:00 to 19:30
• Bedtime means 22:00 to 23:30
• The time bands can be individualised for each service user and the information kept alongside their medication records, beside their medication storage or within their Care Plan. Care will be taken to ensure that the times between doses are sufficient.
Discontinued Items
• Ensure the service users records are updated
• Record in the Visit task log and ensure that there is clear communication with any other visiting care staff(s) to avoid medication errors arising.
Change of Dose
When a Prescriber amends the dose of a medication part-way through the MAR, the following procedure will be followed by staff:
• Obtain written confirmation of the dose change.
• Immediately after the last administration entry, record ‘stopped on date and time, dose change’ and sign entry.
• Mark a single diagonal line through the medication details box to indicate clearly that the medication has been stopped
• Take care to ensure that there is an adequate quantity of medication available if the dose has been increased
• Inform the visiting care staff of the changes and ensure that amendments are easy to understand in the service user's home
Change of Times or Frequency of Administration
• Update the records and/or system with the new information.
• If the original prescription says, 'one three times a day' and the service user wants to go to bed earlier than they used to, then you can bring the dose forward to fit in with their new routine. The GP will not necessarily have to be involved in this decision if the original prescription does not have a specific time on it.
• There must not be numerous entries at 22:00 recorded as 'not taken' because the person was asleep. The time of administration must be brought forward.
• If the frequency is being changed, then ask the Prescriber to confirm this in writing or follow the organisation’s procedure for verbal instructions
• Care must be taken that doses are not administered too close together and guidance will be sought from the prescriber
Change to 'When Required' or 'for Regular Administration'
• Ask the Prescriber to confirm this in writing
Instructions on Dispensing Labels
If the instruction on the MARs or eMARS task log is different from the instruction on the dispensing label, then the information on the MARs/ task log must explain why. This might be because the dose was originally to “take two in the morning” and it has now been changed to “take one in the morning”. As the dose was reduced, there is sufficient supply for the person so there is no need to get another prescription dispensed. If there is no clear explanation, advice must be sought from the registered manager or senior member of staff.
Reviewing MARs
• The Registered Manager will ensure that 10% of MARs are audited each month and any themes or trends are discussed at the quality meetings.
MAR Omissions
• If a care staff realises at any time that they have omitted to complete the task once they have left the service user's home, they must contact the Registered Manager for advice.
• An investigation will be started, and consideration must be given depending on the medication and the impact on the service user's health and wellbeing, as to whether a Safeguarding Notification needs to be raised
• Any trends in errors or omissions will be tracked to identify any administration and recording issues
Time-Sensitive Medication
Prescribers, supplying pharmacists and dispensing doctors must provide clear written directions on the prescription and dispensing label as to how each prescribed medicine will be taken or given.
For time-sensitive medicines this includes:
• What the medicine is for
• What dose must be taken?
• What time the dose must be taken, as agreed with the Service User
Registered managers or senior staff will record any additional information to help manage time-sensitive and when required medication in the Care Plan.
Patient Information Leaflets
The supplying pharmacist or dispensing doctor must supply a Patient Information Leaflet for each medicine supplied. Care staff will ensure that an up-to-date Patient Information Leaflet for each prescribed medicine is kept in the Service User's home
16.MMSOP 09 –Controlled Drugs
Controlled Drugs (CDs) are those defined by the current Misuse of Drugs Regulations 2001, which classify CDs into 5 schedules according to the level of control required.
In Domiciliary Care, CDs will be received and stored in the same way as all other prescribed medicines.
All staff involved with checking and administering the CD must be trained and assessed as competent to administer medication.
Recording
• Administration of the CD must be recorded on the service user's MARs/ task and documented in the Care visit record.
• The strength of liquid CDs must be clearly marked as ‘x’ mg/ml on the MAR next to the drug name.
• The dose of medicine must always be placed on a separate line, e.g.
• Oramorph 10mg/5mL Oral Solution TWO 5ml spoonfuls taken when required up to 4 times daily
Identifying a Controlled Drug
Commonly seen products are listed below but this list is not exhaustive:
• Oral drugs include MST Continus®, Sevredol®, Zomorph®, MXL®.
• Patches include: BuTrans®, Durogesic DTrans®
• Oramorph® Oral Solution (10mg/5ml) must be recorded as a CD because of the risks involved in its use.
Oral Liquid Controlled Drugs
• These must be measured and administered using an oral/enteral syringe. These are available from the pharmacist.
• Where possible, the top of the oral liquid bottle will have a press-in bottle adaptor of the correct size inserted to ensure that the dose can be measured accurately.
• Liquid oral CDs must always have the dose clearly indicated only as the volume in milliliters on the MAR
• Pharmacy medication labels will always show the dose in this way e.g., TWO 5ml spoonfuls (a 5ml oral syringe is equivalent to a 5ml spoon for measuring and the syringe must be used as there is less chance of spillage)
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PRN Controlled Drugs
For ‘when required’ dosing there must be specific instructions for the care staff on the dose, frequency and maximum number of daily doses.
Service Users who Self-Manage
Service users not requiring support with medication will keep and take CDs themselves. Care staff must report if service users are leaving any medication lying around, including any known to be a CD, where they may be a risk to others and may be at risk of being stolen.
The risk assessment process places responsibility on the Service User who keeps the CDs. Monitoring and review of the risk factors must take place and where there is a change in the Service User's condition or concerns about capacity, this must be reported to the registered manager. A review following the principles of the Mental Capacity Act 2005 must then take place.
Collecting Controlled Drugs
• Care staff who have to collect CDs as part of the Service User's Care Planmust provide identification at the pharmacy
Emergency Supplies of Controlled Drugs
• Emergency supplies of most CDs are not permitted, a valid CD prescription must be in place to get supplies from a pharmacy.
• Ordering processes should be robust to ensure Service User’s do not run out of medication, where this is part of the care plan.
Storage of Controlled Drugs
• Where the Service User manages their own medication, they will decide where and how to store medication including CDs Where possible, they must be stored in a safe place and as per the storage instructions
• Where care staff are supporting with medication administration, the storage requirements of any CDs will be clearly documented in the Service User's Care Plan. Any concerns in relation to the storage of a CD must be reported to the manager immediately
Disposal of Controlled Drugs
• Service User's medication can only be disposed of with their consent. Responsibility for the safe disposal of medicines (including tablets, capsules, eye drops, tubes of cream, patches etc. and CDs) rests with the Service User, their family, or the person identified in the Risk Assessment
• Where medication administration support is given, staff may need to make arrangements for the medication to be returned to a local pharmacy
• This will have been agreed with the service user and details will be in the care plan
• The returns must be completed and signed by the pharmacy staff when returning medicines for disposal using Appendix 4 Medicines return to Pharmacy form
Errors, Omissions or Near Misses
• If an error occurs when a CD is given, as with any other medicine, this may have serious consequences for the service user.
• The Care staff will first contact the Service User's GP for advice.
• If theGP is unavailable or it is out-of-hours, 111 must be contacted, or 999 if considered appropriate.
• The Care staff must also speak to the registered manager, senior staff, or care staff on call.
• Follow the Accident and Incident Reporting Procedure
• If there have been serious consequences for the service user as a result of an error or omission, then a regulatory notification will be submitted to the Care Quality Commission and Provide Controlled Drug Accountable Officer (CDAO) Nisha Desai 07580 911601 Nisha.desai@nhs.net
Controlled Drugs and the Death of a Service User
If a Service User dies suddenly or unexpectedly, medication including any CDs will not be removed from the home without prior permission from the coroner as they may be required by the coroner.
17. MMSOP 10 –Over the Counter Medication
Management of Homely Medicines
• Service users must not be given any of the care staff's own medicines.
• The care staff must not take 'over the counter' (OTC) medication bought for the service user.
• OTC remedies must be stored securely and separately from the Service User's prescribed medicines
Service Users and Homely Medication
• Relatives who buy OTC medication for service users will be encouraged to contact the GP or Pharmacist for their advice regarding proposed OTC medication
GP or
other
Health Care Professional Request for OTC Self-Care Medicine
• Care staff must ask the GP/Health Care Professional to check potential interactions with the service user's prescribed medicines.
• Care staff will record verbal or written instructions in the service user's Care Plan to include:
• Dose and directions for use.
• Period of treatment.
• How long the condition should take to resolve, and what actions to take if it does not resolve.
18. MMSOP 11 –As Required and Variable Dose Medication
PRN Medication
Staff administering medication will have the appropriate training and follow the procedures set out in the relevant medication management policies and Standard Operating Procedures (SOPs). However, when administering PRN medication, the following points need to be considered:
• If PRN medicine is administered on a regular, rather than an occasional basis (best practice is no more than 3 days), a referral to the prescriber will be considered for a review of the service user's medication. This action must be clearly recorded in the Service User's Care Plan
• Should the PRN medication not have the expected effects, the prescriber will be contacted. This action must be clearly recorded in the service user's Care Plan
• All PRN medication that is prescribed must give details of a maximum of how much and how often a medication can be administered
To ensure that the medication is given as intended, a specific plan for administration must be recorded in the Care Plan. Information should be documented in the Care Plan on:
• The reasons for giving the 'as required' (PRN) medicine
• How much to give if a variable dose has been prescribed
• What the medicine is expected to do
• The shortest time to wait between doses if the first dose has not worked.
• PRN medicines will normally be kept in their original packaging.
Consideration will be given to the service user's capacity to refuse the medication. When providing staff with information, the needs of the service user must be identified, e.g., if signs of pain are expressed in a non-verbal way.
A record will be made of evidence, on each visit, whether the service user was offered the medication and the reasons for not offering will be recorded. The medicines should be offered in a person-centered manner. Offer the medicines to the service user when they are experiencing symptoms Make a record of the exact time and the amount of medicine given
The Care Plan will detail the circumstances when the medication is or is not required. Staff will be able to explain why the medication is required.
If medicines do not have the expected effects (such as effective pain relief), contact the prescriber. Keep a record of responses from prescribers about queries to medicines.
In the case of medication prescribed to be taken “as necessary” or “as required” (PRN), the reason for needing the medication must be made clear on the medication label, on the MAR and in the Care Plan.
Variable Dose Medication
When variable dose medication is prescribed (for example, give ONE or TWO tablets), it is essential that the actual dose given is recorded. This will be done on the MAR/eMARor where considered necessary for clarity, a supplementary recording sheet could be used. Staff will ensure that a person-specific procedure is in place, similar to that used for “as required” medication, which details how the dose is to be given as advised by the prescriber. The procedure will be kept with the service user's MAR. The procedure will be reviewed at least every 6 months, or sooner if circumstances change.
19. MMSOP 12 –Warfarin Good Practice Guidance
• Warfarin is an anticoagulant medication that requires close monitoring.
• Warfarin tablets must be taken at the same time each day with a full glass of water.
• If a dose is missed, a note must be made on the blood test form and the Medication Administration Record (MAR). Continue the next day with the normal dose, do not give an extra dose to ‘catch up’
• Warfarin will be administered from original packs and will not be included in Monitored Dosage Systems, e.g., nomad or dosette boxes
• It is important that the Care partitioners administering medicines are familiar with the different colours of the various strengths of Warfarin tablets, as different colours (strengths) of tablets may be required to make up a dose
• Always double check the most recent International Normalised Ratio (INR) report when giving a dose. It is essential that dosages are not given from old INR reports.
• If you have not received the record within 3 days, contact the anticoagulation service or GP.
• If there are any concerns that the INR result for a Service User is out of date, contact the anticoagulation service or GP for advice.
Identifying Concerns
Like all medicines, anticoagulants have side effects. The most common side effect of anticoagulants is bleeding. You must contact the Service User's GP immediately if they experience any of the following:
• Nose bleeds that last for more than 10 minutes
• Blood in vomit or sputum.
• Passing blood in urine or faeces.
• Passing black coloured faeces.
• Severe or spontaneous bruising
• Unusual headaches
• Suffered a fall.
• For women, heavy or increased bleeding during your period or any other vaginal bleeding
Warfarin Tablets
Warfarin is available in four different strengths of tablets, 500 micrograms, 1mg, 3mg and 5mg. Care must be taken to ensure the correct strength of tablet is chosen.
• 500 micrograms (0.5mg): white tablet
• 1mg: brown tablet
• 3mg: blue tablet
• 5mg: pink tablet.
Warfarin and Other Medication
• Many medicines can interact with anticoagulants. If, during a course of anticoagulants, a service user is also starting or stopping another medication, the prescriber may advise that they must have a blood test within 5 to 7 days of starting or stopping the new medication. This is to make sure that the INR remains within the desired range
• Oral anticoagulants interact with a wide variety of other medicines (for example, commonly prescribed antibiotics and painkillers), in most cases leading to an increased anticoagulant (blood thinning) effect. Before using over-the-counter medicines, including alternative remedies, care staff must get advice from the pharmacist. Where service users are self-managing, they will also be advised to seek advice
Warfarin and Diet
• It is important for service users to eat a well-balanced diet. Any major changes in diet may affect how a service user's body responds to anticoagulant medication
• Foods rich in vitamin K may affect an INR result. Such foods include green leafy vegetables, chickpeas, liver, egg yolks, cereals containing wheat bran and oats, mature cheese, the seaweed found in sushi, blue cheese, avocado and olive oil. These foods are important in a diet but eating them in large amounts may affect the INR result. It is important to take the same amount of these foods on a regular basis. It is the change in the vitamin K intake that affects an INR result
• A moderate intake of alcohol will not affect anticoagulation but changing the amount a Service User drinks or drinking large quantities is dangerous
• Drinking cranberry juice and possibly grapefruit juice can also affect INR levels and so must be avoided in large quantities
• If the service user suddenly changes their diet and it is thought that this will interfere with their warfarin, the patients GP should be notified with their consent, also advise that the service user tell the anticoagulation clinic at their next appointment.
INR Blood Results
• For most service users the anticoagulation service will usually contact the GP with details of a service user's INR test result, new dose and the date of the next blood test The service user may also be notified directly.
• Service users will continue to take their previous dose of Warfarin until they receive this information in written form from the GP.
• The new dose may differ on different days of the week, and this will be clearly stated in the letter/email.
• The anticoagulation service may need to telephone the care provider if the dose needs to be changed urgently.
Good Practice - Service User commencing treatment
When a service user is initiated on Warfarin, this must be recorded in the Care Plan stating the:
• Location where anticoagulant therapy is managed (i.e. at the anticoagulation clinic at the hospital, GP practice or community pharmacy)
• Date the Warfarin commenced.
• Medical condition it is prescribed to treat, e.g., atrial fibrillation.
• INR target and range
• Date of the next INR test – contact prescriber if it is not stated.
• Current dose, in milligrams (not number of tablets)
• Time of day the dose is to be given.
• Date to stop treatment, if applicable
• Dosing instructions up to the next INR test.
Good Practice - Maintaining the Service User's Warfarin treatment record
• Periodically the service user will need to have a blood test to determine the INR reading
• It must be established at the onset where the test is performed
• The test may result in a change in the Warfarin dose
• The frequency of the blood test is dictated by the INR reading and is specific to each service user.
• The date of the next INR test will be decided at the time of dosing and must be documented in the Care Plan
• For effective handover of information to staff visiting the service user, ensure that appropriate staff are aware if a Service User has had an INR test and when/how the results are expected to be received. This may result in the next dose of Warfarin being altered
• The information received from the clinician managing the anticoagulation will include the date of the last INR test, the dose of Warfarin, and the date of the next INR test
• When a service user is discharged from hospital, they may be prescribed Warfarin doses for a few days only. The manager must contact the ward that discharged the Service User if:
• The dosing instructions run out before the next INR test.
• There is no date for the next INR test.
Good Practice - Receiving changes to the Warfarin dose
Where the dose of the Warfarin is changed due to the INR reading, or changes to other medication the Service User may be taking, then:
• Observe the service user's anticoagulant record for the current dose of Warfarin.
• Any changes to the dose received by telephone must be verified by another suitably qualified staff member and a written copy or email requested. Written confirmation will ensure that there is documentation of the change in dose from the clinician managing the Service User's therapy
• When new dosing instructions have been received, the MAR must be updated with the new dose and date of the next INR test. Two signatures are required to check the daily dose regime with the clinician’s instruction
Good Practice - Administering the Medication
Due to the variable dose of Warfarin, it is unsuitable to be placed in a monitored dosage system, e.g., Dosette Box Therefore, it will be supplied by the community pharmacy in an original pack.
• Check the service user’s current dosage instructions (in anticoagulant record book or equivalent) against dosage schedule on the electronic task to ensure that they are the same
• Check if there are different strengths prescribed in order for the Service User to receive the prescribed dose.
• Check if the service user is prescribed a variable dose (different doses to be given on different days, e.g., 2mg one day alternating with 3mg the next).
• When variable doses are prescribed, document on the MAR, electronic task and in the Care Plan the combination to be used in order for the Service User to receive the correct dose, e.g., 2mg dose = 2 x 1mg tablets, 3mg dose = 1 x 3mg tablet.
• Check the service user's name, the drug name, the strength of the tablets and the expiry date on the original pack supplied by the community pharmacy.
• Warfarin will be taken at the same time each day, generally around 6pm. This is to allow any urgent change to the Warfarin dose to be made following a blood test earlier that day.
• It is very important that Warfarin is given daily as prescribed. Missing doses of Warfarin may have serious consequences. Please ensure that all staff are aware of this. It is not acceptable to omit a dose of Warfarin due to the service user sleeping
• If a dose is missed at the prescribed time, it can still be administered on the same day, i.e., before midnight. If staff realise the previous day’s dose was missed, a double dose must not be taken. The missed dose must be documented and reported to the clinician managing the Service User’s Warfarin as soon as possible. Subsequent doses will be taken at the usual time
• You may wish to consider routine auditing of MARs for Warfarin administration
Good Practice Guidance - Signing the MAR following administration
• The MAR/electronic task must be completed immediately after care staff have administered the Warfarin to the Service User
• If there is a combination of tablets to be taken, then this must be entered on the MAR/ electronic task to inform others of how the dose was given
Good Practice Guidance - Service User carrying Anticoagulant Alert Card and having a yellow book
• Service users taking Warfarin must have a copy of the ‘NHS Oral Anticoagulant Therapy – Important information for patients’ (yellow book). The alert card is to be carried with the Service User when leaving their home, e.g., day excursions.
20. MMSOP 13 –Covert Medication
It is recognised that there may be certain, exceptional circumstances in which covert administration may be considered to prevent a service user from missing out on essential treatment. In such circumstances and in the absence of mental capacity, the following considerations may apply:
• The best interests of the service user must be considered at all times
• The medication must be considered essential for the Service User's health and wellbeing or for the safety of others
• The decision to administer medication covertly must not be considered routine and will be a contingency measure
• Any decision to do so must be reached after assessing the care needs of the Service User individually
Establish the Service User's Ability to give Informed Consent
This will be done via a discussion directly with the service user about their medication. If the service user consents, then covert medication will not be used. If the Service user consents but there is doubt about their capacity, then the principles of the Mental Capacity Act (MCA) must be followed, and medication will not be given covertly. It must be noted that no one, not even a family member, can consent on behalf of someone else when the person concerned is an adult with capacity
Establish the Reason why the Service User does not Wish to Take the Medication
Consideration will be given as to whether this reflects a concern about medication, whether an advance directive regarding refusal of medication exists or whether there is a religious or cultural belief. All are valid reasons for declining medication and must be respected. The Service User's reasons for refusal will be recorded in their records.
Ensure
that
Alternatives have been Explored
Alternative preparations must be offered, and flexibility (where possible) given. Research shows that medication acceptance is improved when the Service User has been involved in the decision-making process and has been enabled to have some control over what is prescribed.
Establish that the Medication is Essential
If consideration is being given to covert administration of medication, then the medication that the Service User is declining must be deemed to be essential for their health and wellbeing or for the safety of themselves or others, and this must be documented in the Service User's care record.
Establish that the Person Lacks the Mental Capacity to Make the Decision Themselves
The principles of the Mental Capacity Act (MCA) must be followed. A capacity assessment will take place directly with the Service User where a conversation will be had about their medication. It must be determined that the Service User is unable to:
• Understand information relevant to the decision, e.g., the risks associated with not taking it.
• Retain this information (if only briefly)
• Weigh up the information/risks involved.
• Communicate their decision.
As detailed in the MCA (2005), all reasonable efforts must be made to help the Service User understand. It must be recognised that capacity may fluctuate during the day and so
the best time of day will be chosen. In some cases, several attempts may be required. A record must be made of methods used to help overcome any communication issues including the use of an interpreter.
If the Service User successfully passes these four tests, then they will be assumed to possess the mental capacity to make the decision themselves, even if their decision appears unwise. In these circumstances, the decision must be respected, and covert medication cannot be given
Discussion About Best Interests
Having established that the Service User lacks capacity, a decision about whether covert medication is in their best interest must, therefore, be had in an open and inclusive way, ensuring that all factors are considered.
The views of people involved in the Service User's Care will be sought, as it is important that the decision to administer covert medication is not an isolated one. Members of the multidisciplinary team, the Service User's family (unless it is clear that the Service User would not wish for them to be involved), people closest to them, and (if applicable) their GP, the Registered Manager, Advocate, or Independent Mental Capacity Advocate (IMCA) will all be invited to express a view.
It is crucial that a decision is reached which is based on what the Service User would have wanted, not necessarily what is best for their physical or mental health. If an advance directive exists, the Service User's wishes stated within it must be respected as they are legally binding.
Where consensus cannot be reached, or there is concern about the restriction of liberty, a DoLS (Deprivation of Liberty Safeguard) application and/or a second opinion may be useful.
Involvement of the Pharmacist
Advice must be sought from the pharmacist when mixing any medication with food or drink. This is to ensure that the medications that the Service User takes are safe to be given in this way and that recommendations can be made about the use of alternative formulations or medications as necessary.
Any changes to the Service User’s medication after a plan for covert medication is put in place will also be discussed with the dispensing pharmacy.
Documentation
In order to be transparent and to provide a clear audit trail, all service users receiving covert medication will have a Care Plan which contains information about why it has been decided that the person will receive their medication covertly.
A clear record of which medicines are being administered covertly and when, must also be maintained. The Care Plan must also include:
• Actions taken to give medication in the normal manner.
• How medication will be administered covertly
• Specialist input to show suitability of the method chosen (for example, crushed or mixed with certain food or drinks)
• Whether the medicine is unpalatable
• Adverse effects (actual or perceived)
• Swallowing difficulties
• Ethical, religious or personal beliefs about treatment
• What to do if the Service User refuses food or drinks
Review
Ongoing attempts to encourage compliance are essential. As far as possible, a reason for refusal must be sought and documented within an appropriate Care Plan. Once taken, the decision to administer covert medication must be reviewed in respect of each Service User on a regular basis, ideally weekly. React Homecare understands that covert medication is not a long-term solution.
General Principles of Covert Medication
Where covert medication is used, the following principles will be seen as good practice:
• Last resort - Covert medication must only be used when all other options have been tried.
• Time limited - It must be used for as short a time as possible.
• Regularly reviewed - The necessity of a covert medication plan will be regularly reviewed.
• Transparent - The decision-making process must be easy to follow and clearly documented.
• Inclusive - The decision must be a team one and will not be taken by one person in isolation. People closest to the Service User will be involved in the decision.
• Best interests - All decisions will be made in the Service User’s best interests, having undertaken a holistic assessment of the impact of covert medication on the Service User
21. MMSOP 14 Administration of Medication via an Enteral Feeding Tube
Enteral feeding tubes provide access to the stomach or small intestine. They are used in cases where there is an obstruction or where a service user has difficulty in swallowing.
The main types of enteral feeding tubes are:
• Nasogastric (NG): a tube passed through the nose directly into the stomach.
• Percutaneous Endoscopic Gastrostomy (PEG) or radiologically inserted gastrostomy (RIG): a tube inserted through the abdominal wall directly into the stomach.
• Nasojejunal (NJ): a tube passed through the nose directly into the jejunum (small intestine).
Care staff should be aware of the risks associated with administration of medicines via enteral feeding tube. Medicines prescribed for administration via the enteral route should be in a suitable formulation e.g. liquids or soluble tablets. If a medicine is not available in a liquid or soluble form, it may be necessary to crush a tablet or open a capsule. Always refer to a pharmacist for guidance on suitable formulations and suitability of crushing tablets or opening capsules. A very limited number of medicines are licensed for administration via enteral feeding tube and most administration of medicines via this route falls outside the product license for that medicine, as does crushing tablets and opening capsules not specifically designed for this purpose. However, this may be the only option for administration of a particular drug.
Care staff should follow instructions about timing of medication and feed meticulously as some medication may interact with feed and require specific gaps between feed and medication.
All service users who require administration of medicines via an enteral feeding tube should have had an additional risk assessment completed by the registered manager (see appendix 5) and should give explicit consent for this to be delegated to care staff (see appendix 6). Care staff will still need to consent the service user as normal as part of their routine day to day care and administration.
Flushing
Flushes are required:
• Before and after each medication administration.
• Before and after feeding.
• Daily if the enteral device not currently in use.
• During continuous feeds the tube should be flushed every 4-6 hours
A pulsating action (‘Push/pause technique’) should be practiced when flushing to promote turbulence within the tube. This ensures adequate flushing of the device and will help to prevent any blockages of enteral device and promote patency of the tube.
Administration of medication via an enteral feeding tube will be classed as Level 3 activity. These types of medicines will normally be administered by a healthcare professional. However, if appropriate a healthcare professional may delegate these tasks to named care workers provided: they agree this with the Registered Manager; the healthcare professional personally provides the required extra training; and is satisfied that the care workers are competent The Healthcare professional delegating the task will remain accountable for the delegation of any aspects of the task and ensuring the individual is competent to carry out the task This includes ongoing assessment and supervision of practice (see Appendix 7 for record of practical assessment).
Care staff should be given the opportunity to refuse to administer medications via specialist techniques if they do not feel confident in their own competence.
22. MMSOP 15 –Medication Away from Home
Medication on temporary transfer or absence for Service Users who require medication administration support
• Service users will, at times, need medicines away from their home. As soon as staff are made aware of the date when the service user will be away, there will be communication with the person who will have responsibility for the service user's medication. If it is another health professional, their name and contact details will be obtained
• If a family member is going to have the responsibility, staff must ensure that they understand the medication that needs to be administered
Communication should include:
• The names of the medicines the service user is taking with them
• Clear directions and advice on how, when, and how much of each medicine the Service User must take
• The time of the last dose taken and next due dose of each medicine
• Contact details for any queries such as those of the Care provider, the supplying pharmacy or the GP surgery
Staff must record clearly who will be responsible for managing medication for service users whilst away from home
Normally service users will be given dispensed containers of medicines when going on leave, e.g., on holiday. However, there may be occasions when an additional supply of medicines is organised for that leave.
Appropriate entries on the service user's MAR must indicate the absence of the service user and the details of the medicines the service User has taken.
If a service user is likely to be out of their home for one or more of the medication administration times, the service user must be given the correct medication names with clear written instructions stipulating the medication dose and time(s) to be taken. These medications must be entered on the medication record as given to the service user, but not administered by the staff.
A risk assessment of the service user’s ability to manage the medication must be documented in the Care Plan by the staff responsible for the medication arrangements at the time the service user leaves home.
Medication on temporary transfer or absence for Service Users who are selfmanaging their medication and for non-healthcare professionals supporting the administration of medication
Ensure that any person responsible for administering or assisting with self-administration of medicines while away from the home is aware of:
• What medicines does the service user need to take?
• Clear directions on how, when and how much of each medicine to take.
• What time the last dose of each was taken
• Contact numbers for queries, such as the contact numbers of React Homecare, the pharmacy or GP.
• Where the Service User lacks capacity, the person who has had responsibility for the medication must advise what medication has been taken and when.
On their return home, the designated staff will check with the Service User to ensure that their medication has been taken correctly, and they will record the answer on the medication visit log. The MAR must have the correct code entered.
Medication
on Permanent Transfer
• On permanent transfer to another care provider, a copy of the current assessment, most recent review and the current Medication Administration Record must be transferred together with the service user.
• Record the transfer of information in the service user’s documentation.
• Original copies of all documents relating to medications for that Service User must be retained in accordance with normal practice for storage and retention.
Sharing of Information on Medications
Where service users are supported with medicine administration, staff will ensure that there is good communication either between the person caring for the service user when they are away from Provide care Solutions, or the health professional who will have responsibility for the service user when they are away.
• Information regarding a service user's medication is confidential and must only be shared with persons or organisations who may need to temporarily administer medicines to the Service User, or who are responsible for reviewing the medications, such as a hospital
• The service user must be informed of the proposed information sharing and authorise it
Regular appointments away from home for Service Users who require medication administration
• Where a service user goes out of their homeregularly, e.g., to day care, and the service user requires medication whilst away, the pharmacist and/or GP must be consulted to assess if an alternative preparation would avoid the need for the dose required whilst away, or if it could be administered at a different time
Medication Administration Requiring Specialised Technique
• Where the Service User requires support with administration by specialised technique, there must be thorough planning to ensure that they receive their medication safely, correctly and at the right time
• If there are additional training requirements, this will be considered, and action taken to ensure that the person responsible for administration is competent to do so
• When required, support will be sought from other members of the multidisciplinary team
• Additional equipment, if required, will be organised and checked and arisk assessment conducted before the journey commences
• All discussions and actions will be documented.
• The dignity and privacy of the Service User must be upheld at all times when medication administration is required outside the home.
23. MMSOP 16 Medication Errors and Near Misses
Reducing the Risk of Medication Errors, Near Misses and Discrepancies
A proactive approach must be taken when identifying where the risks are in relation to medication management. To achieve this, the following principles apply (this list is not exhaustive):
• Any member of staff that is responsible for medication is competent, trained and accountable for their actions as per their code of professional conduct (where applicable) or the organisation’s policy.
• Staff feel supported and able to raise concerns directly and in a timely manner. Refer to the Whistleblowing Policy and Procedure (Freedom to Speak Up (whistleblowing) Policy).
• Systems and processes for all aspects of medication management are followed as per the suite of medication policies and procedures
• Issues arising from partnership working are managed in a proactive and timely manner.
• Staff are aware of and adhere to notifications from national safety alerts and notices (refer to the Distribution of Safety Alert Broadcasts, Rapid Response Reporting and Safety Notices Policy and Procedures)
• Best practice is followed at all times and staff maintain their knowledge and keep updated with changes
Action to be Taken by a Member of Staff Involved in a Medication Error or Near Miss
The following actions must be taken:
• As soon as the error or near miss is identified, assess the Service User's condition to establish if the Service User has suffered any harm.
• If harm has occurred and the Service User is unwell, call 999
• If the Service User does not appear immediately unwell, report the incident to the doctor responsible for the Service User's care. During out of hours contact 111
• Discuss and agree who will inform the Service User that a medication error has occurred (duty of candour)
• Document the nature of the incident in the Service User's records.
• Report the incident immediately to the Service manager.
• If the incident involves a dispensing error, inform the relevant pharmacy immediately.
Process for Managing a Medication Error that Results in Immediate or Potentially Life-Threatening Risks
• Are there immediate/potential life-threatening risks to the service user from the incident? These can include:
• Airway obstruction
• Breathing problems
• Cardiac arrest
• Central Nervous System depression
• Severe hypotension
• Hypovolaemia
• Hypoxia
• Bleeding
• Circulatory problems, i.e., bradycardia, tachycardia
• If there are identified life threatening risks, seek emergency medical help immediately by calling 999.
• Assess and manage the patient using an ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach and life support measures if required.
Action to be Taken by the Registered Manager/Senior Care Staff
In the first instance:
• Assess the status of the service user if relevant and check if any harm has occurred
• Ensure that all appropriate support has been offered to the members of staff involved in the incident
• Confirm that the service user's GP has been informed and that the incident has been reported
• Ensure that the incident is recorded on the Service User's notes and an incident log made.
Once the Service User is stable, the Registered Manager/Senior staff must:
• Ensure that a CQC notification is made if there was harm to the Service User.
• Ensure that Local Authority is informed in line with local safeguarding procedures and in line with any contractual requirements (staff must refer to the Safeguarding Policy and Procedure at React Homecare and Local Authority safeguarding policies and procedures).
• Consider if Duty of Candour applies and refer to the Being Open and Duty of Candour to determine this.
• An investigation must be carried out using a Root Cause Analysis (RCA) to review what caused the incident.
• At the appropriate time, allow the member(s) of staff involved in the incident to reflect on the circumstances and identify their own learning
• Identify if there are any training or performance issues with the member(s) of staff, and depending on the level of risk, take any necessary actions which may involve immediately suspending a member of staff from prescribing, dispensing, preparing or administering medication
• Reflect on ensuring that there remains an open, honest and transparent culture to raise concerns, and consider reinforcing key supportive policies to staff.
Action After the Incident has Occurred – Staff
After a medication error or near miss has occurred and all of the necessary immediate actions have been taken, it is important that there will be an opportunity for the staff to discuss the incident with the registered manager as soon as possible after the incident. The purpose of the discussion is to:
• Enable the members of staff to reflect on the circumstances
• Allow the members of staff to discuss how they feel and discuss any concerns that they may have
• Identify if there are any training or performance issues with the members of staff
• Determine if the medication incident is a repeat incident (check if the member of staff has made a similar medication error previously and in what timeframe).
• Dependent on the severity of the error/near miss, ensure that all appropriate support has been offered to the members of staff.
Being Open with the Service User Following a Medication Incident
It is important to be open and honest when things go wrong, therefore it is of great importance that a service user is informed if a medication error has occurred.
• The Service User must be informed at an appropriate time and an apology offered
• If the error is of a serious nature, following the formal investigation and at the appropriate time, the service user must be offered an opportunity to discuss the outcome of the investigation and to discuss its findings. This provides an opportunity to reassure the Service User that the provider is keen to always learn any lessons from medication errors and to prevent similar occurrences in the future
• Consent will be obtained from the Service User before discussing any medication errors with their family. If the Service User is unable to consent due to the lack ofmental capacity, the person responsible for their best interests will be informed
• Care will be taken not to cause unnecessary alarm and information will be provided in a way that is easy to understand and enables the Service User to ask questions
• If at any time the Service User or their representative is unsatisfied with the management of the medication incident, staff must signpost them to the complaints process as detailed within the Procedure for Managing Complaints and Compliments
24. MMSOP 17 Auditing and Monitoring of Medicines Processes
The Registered Manager will ensure that there is a complete, documented audit trail from the receipt through to the administration and/or disposal of all medicines.
The Registered Manager will ensure that policies and procedures for medicines handling are accessible to staff and can evidence through audit that those policies and procedures are adhered to by staff.
There must also be evidence through audit of the Service User's informed consent and that the correct procedure has been followed if a Service User refuses their medication.
This system of auditing seeks to identify failures and eliminate medication errors and other medication-related risks.
Audit Cycle
The Registered Manager will be required to undertake audits of medication management. The audit schedule will be agreed in advance and the schedule cascaded to staff.
As a minimum, 10% of MARs will be audited, the results will be evaluated, and any themes or trends will be identified. Each Service User must have at least two MAR audits per year.
The themes or trends will be shared with the Senior Management Team. Where changes are required to either training, procedure or policy, action will be taken to ensure continuous improvement. Where the audit highlights individual Care staff concerns, these will be addressed directly with the Care staff
Medication Training
Registered Manager will:
• ensure that all staff have an annual review of their knowledge, skills and competencies relating to managing and administering medicines. Records will be retained on staff personnel files.
• identify any other training needed for staff responsible for managing and administering medicines.
• Ensure that if a medicine-related safety incident occurs, this review may need to be more frequent to identify support, learning and development needs.
• Ensure the content of the medication training materials will be reviewed annually to ensure that it is up to date and reflects best practice.
